Phacomatosis cesiomarmorata with hypospadias and phacomatosis cesioflammea with Sturge-Weber syndrome, Klippel-Trenaunay syndrome and aplasia of veins -- case reports with rare associations

Phacomatosis pigmentovascularis (PPV) is a rare genodermatosis characterized by the co-existence of an extensive vascular and a pigmentary nevus with or without extracutaneous manifestations. We report two such rare cases. The first is a 3-year-old boy exhibiting a rare association of cutis marmorata telangiectatica congenita with aberrant dermal melanocytosis along with hypospadias and melanosis oculi (traditionally classified as PPV type Vb or phacomatosis cesiomarmorata - Happle's classification). The other patient is a 5-year-old boy with Sturge-Weber syndrome, Klippel-Trenaunay syndrome, aplasia of iliac, femoral, and popliteal veins and congenital heart disease, associated with aberrant dermal melanocytosis and melanosis oculi (also classified as PPV type IIb or phacomatosis cesioflammea). These sporadic cases display a unique constellation of additional, previously unreported systemic associations, which will further expand the clinical spectrum of phacomatosis pigmentovascularis.

Treatment of a massive left femoral arteriovenous malformation using an innovative modular hybrid bifurcated stent graft system

BACKGROUND

Arteriovenous malformations (AVMs) are difficult to treat and manage because of their high recurrence and complication rates. In particular, peripheral AVMs pose multiple clinical challenges because of their high flow rates and the frequent presence of multifocal nidi.

METHODS

A 37-year-old man with a massive AVM involving the left common, deep, and superficial femoral arteries and veins is discussed herein. After initially being treated at another facility with coil embolization in 2005, he went untreated until he presented to us in April 2012 with swelling, tissue breakdown, leg ulcers, pain, and difficulty walking. When our extensive packed coil embolization proved ineffective, we knew that other standard treatments would be impractical, given the size of the AVM. Because the patient was in significant danger of bleeding, we treated him endovascularly with a system of modified stent grafts to exclude the arterial branches feeding multiple nidi.

RESULTS

Postoperative computed tomography angiography scans revealed exclusion of the AVM and excellent flow to the deep and superficial femoral arteries. At 6 months postoperatively, the patient had no complications, and the leg continued to decompress. At 8 months postoperatively, we started additional treatment using percutaneous sclerotherapy to treat residual areas.

CONCLUSION

A modular hybrid bifurcated stent graft system is a viable option to treat or manage complex peripheral arteriovenous malformations.

Femoral arteriovenous fistula associated with calf pain 2 months after removal of a haemodialysis catheter

Double-lumen catheters are widely used to achieve temporary access to circulation in patients requiring acute haemodialysis (HD); however, several complications are associated with the insertion of these catheters. Arteriovenous fistula (AVF), a rare but significant complication of catheter insertion, has been reported in several cases. In this report, we describe a case of a right femoral AVF that caused calf pain 2 months after HD catheter removal. The right ankle-brachial index was 0.46, and the diagnosis of AVF was confirmed using colour Doppler ultrasound and three-dimensional CT. The fistula was managed by surgical vascular repair. The right ABI improved to 1.06, and the absence of fistula was confirmed using three-dimensional CT. Therefore, physicians and nursing staff should be aware of the potential of this complication and should perform clinical and medical examinations at the insertion and removal of temporary HD catheters.

Rare urogenital malformation associated with complex vascular malformation -- case report

BACKGROUND

Class 3 urogenital malformations are a rarely encountered in the clinical setting. The association with complex vascular malformations represent a challenge in diagnosis and intraoperative management with an enhanced degree of the complexity.

CASE PRESENTATION

Young female presented to the emergency department with pain in the left lower quadrant and unspecific abdominal symptoms that appear regularly one week prior and during her menstruation. Diagnostic studies and intraoperative findings lead to the diagnosis of a rare urogenital malformation associated with complex vascular malformations. In conclusion the most helpful diagnostic study was the abdominal MRI. Regarding the functional status of the postoperative urogenital tract no clear assessment can be made yet.

Observations on the flow characteristics of blood flow in arteriovenous fistulae (experimental)

Hemodynamic play a very significant role in the pathophysiology of intracranial arteriovenous malformation. The surgical decisions are based on the understanding of the complexities of the flow. Quantification of the abnormal flow is difficult. The mathematical models provide limited information due to the simplicity of the design of these models. Flow of fluid in a tube is very sensitive to small changes in the diameter. We studied the flow characteristics of a fistula by introducing accurately machined acrylic fistulae between the femoral arteries and veins of dogs. The influences of systemic arterial pressure, diameter of the arterial feeders, volume of blood flow, velocity of flow and the diameter of the shunt on the flow of blood across the shunt were studied. Our experiments suggest that the flow characteristics of an arteriovenous fistulae are complex and are influenced by small changes in the diameters of the fistula and the feeding artery. Our model demonstrates the occurrence of the anomalous flow reduction in the fistula and steal phenomenon and is therefore a more realistic representation of the clinical situation. The design of a mathematical model should include the diameter of the fistula if it is intended to replicate the hemodynamic characteristics of an arteriovenous malformation more faithfully.

Incomplete transposition of the common femoral artery and vein

Anatomical variations of the great saphenous vein, femoral artery and femoral vein at the inguinal level are rare. Modifications in the anatomical relationships among theses vessel can cause technical difficulties. There are two reports in the literature of the complete transposition of the femoral artery and vein. Both patients had large varicose veins only in the limb that presented the variation, which suggested an extrinsic compression. In the present paper, we report a case study of a patient with an incomplete transposition of the femoral artery and vein. Specifically, the common femoral vein and the saphenofemoral junction were completely overlapped by the common femoral artery. Although this anatomical variation did not present any clinical signs, it required a more complex surgical procedure.

Vessels in femoral triangle in a rare relationship

The femoral region of the thigh is utilised for various clinical procedures, both open and closed, particularly in respect to arterial and venous cannulations. A rare vascular pattern was observed during the dissection of the femoral region on both sides of the intact formaldehyde-preserved cadaver of a 42-year-old Indian man from West Bengal. The relationships and patterns found were contrary to the belief that the femoral vein is always medial to the artery, just below the inguinal ligament and the common femoral artery. The femoral artery crossed the vein just deep to the inguinal ligament so that the femoral vein was lying deep to the artery at the base of the femoral triangle. Just deep to the inguinal ligament, the profunda femoris artery (deep femoral artery) arose from the femoral artery, and the long saphenous vein drained into the femoral vein. The embryological and clinical correlations are discussed.

Axial transformation of the profunda femoris vein: formation, relations and course in a cadaveric specimen

When the superficial femoral vein is obstructed by thrombosis, the profunda femoris vein provides an important collateral pathway, transforming into the axial vein of the lower limb. When operating on a transformed axial vein, a surgeon should be aware of the formation, the relations and the course of the vein. A precise description of these anatomical features is not feasible on the basis of ultrasound, venographic or surgical study but only from anatomical studies. We present a case of axial transformation of the profunda femoris vein found in a cadaver, focusing on the anatomical features of the transformed axial vein.

A rare variation of the profunda femoris vein in the popliteal fossa

The profunda femoris artery is normally accompanied by a profunda femoris vein (deep femoral vein), which begins at the adductor magnus with various tributaries and drains into the femoral vein at the femoral triangle. Very rarely, the profunda femoris vein establishes communication with the popliteal vein. We present an anomalous profunda femoris vein in a 62-year-old male cadaver whose vein was located in the popliteal fossa as a direct communicating channel between the popliteal vein and the femoral vein.

Das Klippel-Trenaunay Syndrom bei gleichzeitigem Vorliegen von Viszeralarterienaneurysmen

Das Klippel-Trenaunay Syndrom (KTS) ist eine kongenitale Angiodysplasie der venösen Gefäßstrombahn mit der Symptomtrias kutane vaskuläre Naevi, Hypertrophie einer Extremität sowie Varikose und venöse Malformation. Die Koinzidenz eines KTS mit arteriellen Malformationen im Sinne von Nierenarterienaneurysmen findet sich in der Literatur lediglich in zwei Beschreibungen. Wir berichten über einen 40-jährigen Patienten, bei dem, neben einem KTS Aneurysmen einer A. renalis, der A. lienalis, der A. mesenterica superior sowie einer A. und V. poplitea beobachtet wurden. Neben der Darstellung des diagnostischen und therapeutischen Verlaufs wird über die in der Literatur dargestellten klinischen Erfahrungen berichtet. Differentialdiagnostisch sind zwei weitere Syndrome, ebenfalls aus dem Formenkreis der Phakomatosen, abzugrenzen: das Servelle-Martorell-Syndrom und das Frederick Parkes Weber-Syndrom.

Early enhancement of the inferior vena cava on helical CT

Arteriovenous fistulas (AVFs) are abnormal communications between the arterial and the venous systems. We describe two cases in which an aortocaval fistula (ACF) and a deep femoral AVF were diagnosed on dynamic computer tomography (CT) by early transient enhancement of the inferior vena cava (IVC). Awareness of the specific CT features found in central and peripheral AVFs and the effects on the arterial and venous systems may enable the radiologist to make the diagnosis.

[Vascular manifestation of von Recklinghausen neurofibromatosis: case report of venous dysplasia]

We present the case report of a patient with neurofibromatosis and regional dysmorphism in the superficial femoral vein. Colour coded duplex sonography revealed an incidental finding: thickening of a short portion of the vein wall with calcification. This unusual finding strongly suggests a causal relationship. Pathological processes in the arteries have often been described in patients with von Recklinghausen's disease (neurofibromatosis). Dysplastic and hyperplastic reactions of the intramural nerve tissues and the smooth muscle elements in the vascular wall have been observed. This leads to the formation of aneurysms and arteriovenous fistulas and to stenosing processes in the peripheral, visceral and cerebral arteries. However, involvement of the veins in type 1 von Recklinghausen's neurofibromatosis has only been reported in old histopathological studies of medium-sized and small vessels.

A rare vascular malformation, Klippel-Trenaunay syndrome. Report of a case with deep vein agenesis and review of the literature

The Klippel-Trenaunay syndrome (KTS) is a rare anomaly characterized by naevus, soft tissue hypertrophy and varicosities which is mainly unknown etiology. Associated deep venous system abnormalities have been reported with KTS. Here, a 4-year-old-boy with KTS was reported, because of the associated popliteal vein, common femoral vein with its deep and superficial branches, and external iliac vein agenesis. The originality of the presented case is that we have never observed such a case before.

Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment

OBJECTIVES

We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF.

BACKGROUND

Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment.

METHODS

A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography.

RESULTS

The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence.

CONCLUSIONS

Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.

Congenital pelvic arteriovenous malformation: uncommon symptoms of lower limb venous hypertension

Congenital pelvic arteriovenous malformations (AVMs) are rare and their clinical behavior is quite variable. A case of congenital pelvic AVM manifesting with unusual extrapelvic symptoms of ipsilateral leg pain is described. The causes of symptoms associated with congenital pelvic AVMs are discussed.

Duplicated popliteal and superficial femoral veins: incidence and potential significance

BACKGROUND

Duplication of the popliteal and superficial femoral veins (PV, SFV) is a normal variant previously reported in up to 25% of limbs. Little clinical significance, however, has been attributed to this apparently common anomaly. The present study was designed to determine the incidence of duplications in individuals presenting for venous incompetence studies, and whether their presence could, in theory, act as a predisposing factor to deep venous thrombosis (DVT) formation.

METHODS

Duplex ultrasound examinations were performed in which venous duplications were actively searched for and recorded. The diameters of both limbs of any duplicated system and the single vessel immediately distal to it were recorded. Using these measurements, the changes in total cross-sectional area (CSA) associated with these anomalies were calculated. In addition, with the knowledge that the volume flow rate must remain constant, the velocity changes associated with such systems were calculated.

RESULTS

A total of 248 limbs from 177 patients was scanned. Duplications were found in 39 (15.7%) of these limbs. Of these, 30 limbs (77%) involved only the SFV, seven (18%) involved both the SFV and PV, and two (5%) involved only the PV. Short-segment SFV duplications were used to calculate the percentage change in total CSA and therefore blood flow velocities. Of the 13 (33%) suitable for such calculations, and calculating for each individual duplicated system, a mean increase in the vessel's total CSA of 42%, which corresponded to a theoretical decrease in blood flow velocity of 36%, was found.

CONCLUSION

The present study confirms the significantly high incidence of duplications of the PV and SFV and raises the possibility of the potential for DVT formation secondary to changes in flow velocities.

Thrombosis in a duplicated superficial femoral vein in a patient with haemophilia A

Venous thrombosis is a very rare occurrence in patients with haemophilia A. We report the case of a haemophiliac in whom initially a calf haematoma was suspected, but neither this nor deep venous thrombosis (DVT) could be confirmed on ultrasound scanning. Subsequently, a high segment venous thrombosis was diagnosed by venography in a portion of a duplicated superficial femoral vein. Treatment with factor VIII (FVIII) and low molecular weight heparin led to a successful resolution. The only other case we have been able to find in the literature occurred during FVIII replacement therapy, which was not the situation with our patient.

Scrotal arteriovenous malformation and its preoperative embolization

Arteriovenous malformations of the scrotum are extremely rare. A case of scrotal arteriovenous malformation and its preoperative embolization in a child is presented.

Proteus syndrome with widespread portwine stain naevus

Proteus syndrome is a rare condition comprising asymmetrical overgrowth of different parts of the body in association with various cutaneous abnormalities. We describe a 3-year-old boy with Proteus syndrome, who presented with hemihypertrophy of the right leg, asymmetric macrodactyly, subcutaneous masses and a widespread portwine stain interspersed with angiokeratomas on the right leg, scrotum and on the middle and left side of the back. Doppler ultrasound of the right leg did not show hypercirculation, but did reveal the absence of the right superficial femoral vein.

Duplicated superficial femoral veins: a source of error in the sonographic investigation of deep vein thrombosis

PURPOSE

To determine whether the number of false-negative ultrasound (US) findings of thrombosis is larger when a duplicated femoropopliteal venous system is present.

MATERIALS AND METHODS

A retrospective review was performed of 381 venograms obtained after initial US findings were considered negative for thigh or popliteal thrombosis in patients in whom deep vein thrombosis was suspected Venograms were evaluated for the presence of thrombosis and the presence and configuration of duplicated superficial femoral veins.

RESULTS

Multiple superficial femoral veins were present on 177 (46%) of the 381 venograms; 149 (84%) were duplex systems. False-negative US findings occurred in four (2%) of 204 patients with single femoral veins and in 10 (6%) of 177 patients with duplicated femoral veins (P = .056, not statistically significant).

CONCLUSION

The frequency of missed proximal thrombosis at sonography appears to be increased when duplicated superficial femoral veins are present. Data from clinical and imaging studies are insufficient to support the adoption of a totally noninvasive imaging strategy.

A rare variation of deep femoral vein

Venous pattern particularly in the lower limbs is of great clinical importance, while ligating the veins to prevent the spread of thrombus. Normally deep femoral vein drains the area supplied by profunda femoris artery, follows the pattern of branches of this artery and ends independently into the femoral vein. However in few cases it establishes communication with popliteal vein of femoral vein at a lower level. In the present study the deep femoral vein replaced most of the popliteal vein by establishing communication with the tibial veins.

Duplication of the superficial femoral vein: recognition with duplex ultrasonography

Duplication of the superficial femoral vein (SFV) is a normal variant seen in 20% of contrast phlebograms. Failure to identify thrombus in one limb of a SFV may lead to inappropriate management and subsequent complications. Colour Doppler imaging (CDI) is now the imaging technique of choice in the diagnosis of a deep vein thrombosis (DVT). The purpose of this study was to identify the prevalence of duplication of the SFV at CDI and to compare this with the known prevalence at contrast phlebography. CDI was performed on 58 healthy volunteers (116 limbs examined). Duplication of the SFV was present in 29 examinations (25%). Ultrasonic measurement of the diameter of the SFV was performed in all patients. In the presence of duplication a significant reduction in the diameter of both limbs of the SFV was noted when compared with an unduplicated vessel. The prevalence of duplication of the SFV at CDI is comparable to that at contrast phlebography. Recognition of this variant may help reduce false negative CDI examinations.

Ultrastructure of the afferent arteries of experimental femoral arteriovenous fistulae in rabbits

Using transmission electron microscopy, the aorta and ilio-femoral arteries of 12 normocholesterolemic rabbits with femoral arteriovenous fistulae were investigated (49 to 895 days post-operatively) to determine whether the fibrofatty lesions in arteries proximal to chronic fistulae were ultrastructurally consistent with human atherosclerosis. The contralateral ilio-femoral arteries from the same animals and the vessels of 4 additional rabbits (2 with femoral arteriotomies) served as control material for comparison. There were microfractures adjacent to complete tears of the internal elastic lamina which had abrupt margins. These tears were observed mostly in the ilio-femoral arteries proximal to the fistula. They were most numerous, extensive and associated with considerable intimal proliferation near the fistula. Further proximally the tears were associated with progression to severe atrophy of the wall, the media in places being reduced in width to no more than 2 or 3 smooth muscle cells without any evidence of cellular degeneration. Intimal proliferation near the fistula and the naturally occurring intimal thickenings at branching sites proximal to the fistula, not only extended peripherally and progressed with time post-operatively, but exhibited ultrastructural changes consistent with atherosclerosis. These changes comprised dystrophic basement membrane, granulovesicular degeneration (matrix vesicles) and necrosis of smooth muscle cells, disruption of the elastic laminae, the appearance of extracellular and to a lesser extent intracellular lipid, adherence of monocytes, accumulation of foam cells, intimal fibrin deposition and sub-endothelial hemorrhage. Such results indicate that augmented hemodynamic stresses associated with femoral arteriovenous fistulae are consistent with those of human atherosclerotic lesions.

Emergency vascular access in a patient with limb agenesis

A 19-year-old white man with congenital agenesis of all four limbs arrived in the emergency room in full cardiopulmonary arrest secondary to Reye's syndrome. The patient was intubated but had no vascular access. After a percutaneous femoral venous line proved unsuccessful, an internal jugular line was placed for venous access. Repeated attempts at percutaneous femoral and axillary arterial line placements were unsuccessful. A femoral cutdown showed 2-mm femoral vessels. The autopsy showed increasingly hypoplastic aortic, iliac, and femoral vessels below the takeoff of the renal vessels. The subclavian vessels were reasonably normal in caliber. This case shows that femoral or axillary vessels in a congenitally amputated limb are not useful for vascular access, and a low threshold should exist for using internal jugular/subclavian veins and the subclavian/carotid arteries if emergency access is necessary.

Iatrogenic femoral arteriovenous fistula as a cause of erectile dysfunction

The authors present a unique case of impotence in a 65-year-old patient caused by an iatrogenic common femoral arteriovenous fistula. After surgical treatment of the fistula, there was a clear improvement of the erectile function.

Surgical treatment of congenital arteriovenous defects

Congenital vascular arteriovenous malformations can be treated by surgery in the majority of cases. Contraindications for surgical correction are only slight cases and very few of the severe cases in which amputation is the only possibility of treatment. After illustrating guidelines for surgical strategy, tactics and techniques of operative treatment are discussed. Results obtained in 52 cases are demonstrated.

Superficial femoral vein transposition in Klippel-Trenaunay syndrome

Use of a superficial femoral vein in competent profunda vein transposition is appropriate in selected cases of Klippel-Trenaunay syndrome; this allows for improvement of venous insufficiency and relief of symptoms secondary to venous stasis.

Erectile dysfunction due to ectopic penile vein

A total of 86/260 patients with erectile dysfunction had venous leakage as (joint) etiology. In 5 of 86 patients cavernosography showed pathologic cavernosal drainage only via an ectopic penile vein into the femoral vein. After ligation of this pathologic draining vessel, 4 of 5 patients regained spontaneous erectability. One patient with pathologic bulbocavernosus reflex latencies needed intracavernosal injection of vasoactive drugs for full rigidity.

Congenital aplasia of the deep veins of lower extremities in children: the role of ascending functional phlebography

Eighty-two children with vascular diseases underwent phlebography. Congenital aplasia of the deep venous system of the lower extremities was diagnosed in 10 children. With ascending functional phlebography, three anatomic variations with different degrees of venous dysfunction were defined: aplasia of the femoral vein with collateral drainage into the common femoral vein, aplasia of the femoral vein with drainage into the internal iliac vein, and total aplasia with drainage into the axillary vein. The phlebographic findings correlated with the symptoms. Patients with type a aplasia had no clinical and radiologic signs of venous insufficiency. Patients with types b and c aplasia had severe venous insufficiency that necessitated supportive treatment. Palliative surgical procedures such as hemorrhoidectomy, clitoridectomy, and excision of bleeding vascular nevi were performed. Ligation or excision of the dilated superficial veins (usually the main channels for venous drainage from the extremity) is absolutely contraindicated. Ascending functional phlebography is therefore essential for correct diagnosis and planning of future therapy.

Anomalies encountered during varicose vein surgery

During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0,04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0,02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0,02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.

[Surgical correction of the venous blood flow in congenital hypoplasia of the deep venous system of the lower extremity]

Problems concerning the surgical treatment of patients with congenital hypoplasia of the deep veins of the lower limb are analyzed. Among 218 patients with angiodysplasia of the lower limbs 108 were found to have a venous form of the lesion, in 90 of whom hypoplasia of the deep venous system was diagnosed from clinico-angiographic findings. Corrective operations developed by the authors (excision of the venous conglomerate or hemangiomas together with the changed subcutaneous fat of the dorsal surface of the foot in combination with replantation of a perforated skin graft and extensive operation of the Linton type) made it possible to achieve regression of the symptoms of severe chronic venous insufficiency of the lower limb in 85% of cases.

[Deep vein malformations in the Klippel-Trenaunay syndrome]

Klippel's syndrome is due to a malformation of the deep veins. From 1944 to 1978 we have operated on 614 cases. In 51 % of these cases the malformation concerned the popliteal vein, in 16 % it concerned the superficial femoral vein, and in 25 % both veins were affected. We had only 3 % of iliac malformations and 1 % of inferior vena caval malformation. In the popliteal vein, ageneses and atresias were of equal incidence, but compressions by fibrous bands were much more frequent. In the femoral vein, compressions were most frequent, followed by atresias. Ageneses were very rare. In the iliac vein, atresias were twice as common as ageneses, whereas with the inferior vena cava we only found ageneses. The obstruction to the deep veins can be sectioned but one must also free the supplying vessels.

[Agenesis of the femoral vein in the framework of vascular dysplasias of the lower limbs. Clinical case]

Venous dilatations of the lower limbs, especially if associated with others abnormalities, may reflect pathogenetic mechanisms far more complex and diverse than plain insufficiency of the sephena, all the way to congenital vascular anomalies of all possible types and still dubious classification. In such conditions a prerequisite of prime importance is the complete exploration of the whole arterial and venous vasculature of the limb, first of all in order to avoid rash therapeutic decisions, and then to help clarify the diagnosis and select the most appropriate treatment from among the numerous technics available.

Anomalies encountered during varicose vein surgery

During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0.04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0.02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0.02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.

Pulmonary embolism secondary to anomalies of deep venous system of the leg

Two cases of recurrent pulmonary emboli secondary to thrombosis in anomalies of the deep veins of the lower limb are presented. In both cases the source of emboli was not evident clinically, and it was only after venography that the venous anomalies were discovered, both being confined to one limb and amenable to surgical intervention. Such anomalies have not previously been reported as sources of venous thromboembolism in adults. The importance of venography in establishing the source of pulmonary emboli, especially when recurrent, is stressed.